The Zipperator! A Novel Model to Simulate Penile Zipper Entrapment

Audience The Zipperator training model is designed for emergency medicine resident physicians and physicians. Introduction Zipper entrapment injuries are an uncommon cause of penile injury in the emergency department, representing an incidence of less than 0.5% of pediatric emergency department visits.1 However, they are one of the most common causes of genital injuries in young boys.1,2 Various methods proposed for releasing the entrapped tissue range from the use of mineral oil as lubrication to techniques to release the zipper mechanism or, in extreme cases, surgical procedures.3–6 A well-designed simulated task trainer would allow learners to practice these methods in a controlled environment conducive to learning 7,8. Given the low frequency of the chief complaint and with a wide variety of release techniques available, the purpose of this study was to build a simulation model that could improve learner confidence in troubleshooting this rarely performed procedure. Although past studies have designed similar task trainers, this novel model was built using a low-cost device (“Operation”) to provide real-time alarm noises that reasonably simulate distress and procedural anxiety for both the patient and provider. Although pain and anxiety are separate outcomes from zipper entrapment release, including a component of these emotions may mimic the same emotional states that patients, their parental unit, and perhaps their provider may experience regarding this chief complaint given its rarity, anatomic vulnerability, and the overall sensitivity of the complaint’s nature. Educational Objectives After training on the Zipperator, learners will be able to: Demonstrate at least two techniques for zipper release and describe how methods would extrapolate to a real patient. Verbalize increased comfort with the diagnosis of zipper entrapment. Present a plan of care for this low-volume, high-anxiety presentation. Educational Methods As part of a voluntary Emergency Medicine curriculum at two different sites, we constructed an inexpensive model for penile zipper entrapment using a household gameboard, “Operation,” and materials that are easily obtainable and assembled in any emergency department. “Operation” was selected for its ability to produce alarm noises in response to excessive movement, which would reasonably simulate distress and procedural anxiety that may be experienced by both the patient and provider. This task trainer was used to teach medical students and post graduate year (PGY) 1–4 resident learners. A brief hypothetical situation was presented to learners, highlighting patient and paternal unit anxiety. Following this, learners were given a survey and asked to complete pre-model training questions immediately prior to using the simulated model. Learners were then given the opportunity for hands-on skills-based practice. Postmodel training questions were made available in the same survey immediately following the exercise. Research Methods This exercise was offered at two sites over a two-year period. Sixty learners participated in the exercise. Participation was voluntary, was not graded nor shared with the residency director, and all feedback was formative in nature. Selected faculty and research assistants provided asynchronous opportunities for learners to practice on the model. Before the exercise, the faculty or research assistant on site presented a brief hypothetical situation to simulate patient and paternal unit anxiety that could be expected in this chief complaint. Each learner was then allowed to select a variety of tools and methods to practice zipper entrapment release. Learners were asked to begin a survey prior to training on the model, and then complete the survey immediately after training on the model to evaluate its educational value. The survey created for this study consisted of a structured questionnaire that contained close-ended questions. Measures evaluated include experience with prior zipper entrapments, comfort with zipper entrapments before and after training on the simulated model, and user experience. Results Before the exercise, 68.3% of learners described their comfort with managing future zipper entrapments as very uncomfortable or totally uncomfortable. Although only 8.3% of learners had treated the zipper entrapment complaint prior to the exercise, 100% of those who had experienced treating the complaint felt that the simulated model was at least somewhat reflective of their experience with a real patient. 71.7% of the learners found the experience enjoyable, although 20% found the experience totally unenjoyable, of note, for unclear reasons and with unclear significance or etiology. After the exercise, 71.7% of learners indicated they felt comfortable to very comfortable regarding future cases of zipper entrapment. Discussion Through the use of a well-known household board game and supplies commonly found in the emergency department, we created a simulated model that could be easily replicated. This simple model provided practice of the hand motions necessary for zipper entrapment release, as well as familiarity with the mental and physical approaches to dislodging the entrapment. The resident physicians who had had a prior zipper entrapment patient reported the model was somewhat similar to actual patient encounters. Overall, this model was well-received by the learners, with most expressing it was enjoyable and feeling it increased their confidence for treating this chief complaint. Some learners had noted the experience was totally unenjoyable. This measure may not be an appropriate endpoint, however, and incongruencies may be addressed by implementing prizes or friendly competition for enjoyment. Another limitation of this study is the leap taken between movement and patient comfort. While possible that learners can manipulate the model to reduce movement of the needle without meaningful reduction in zipper movement, observation by the instructor was sufficient to ensure this finding was not observed in our learner population. We therefore submit this cheap, simple model as a potential method to teach approaches to teaching a low frequency, high anxiety chief complaint. Topics Penile entrapment model, penile entrapment release, Emergency Medicine, Urology, Clinical/Procedural Skills Training.


INNOVATIONS
2. Verbalize increased comfort with the diagnosis of zipper entrapment. 3. Present a plan of care for this low-volume, high-anxiety presentation.
Educational Methods: As part of a voluntary Emergency Medicine curriculum at two different sites, we constructed an inexpensive model for penile zipper entrapment using a household gameboard, "Operation," and materials that are easily obtainable and assembled in any emergency department. "Operation" was selected for its ability to produce alarm noises in response to excessive movement, which would reasonably simulate distress and procedural anxiety that may be experienced by both the patient and provider. This task trainer was used to teach medical students and post graduate year (PGY) 1-4 resident learners. A brief hypothetical situation was presented to learners, highlighting patient and paternal unit anxiety. Following this, learners were given a survey and asked to complete pre-model training questions immediately prior to using the simulated model. Learners were then given the opportunity for hands-on skills-based practice. Postmodel training questions were made available in the same survey immediately following the exercise.
Research Methods: This exercise was offered at two sites over a two-year period. Sixty learners participated in the exercise. Participation was voluntary, was not graded nor shared with the residency director, and all feedback was formative in nature. Selected faculty and research assistants provided asynchronous opportunities for learners to practice on the model. Before the exercise, the faculty or research assistant on site presented a brief hypothetical situation to simulate patient and paternal unit anxiety that could be expected in this chief complaint. Each learner was then allowed to select a variety of tools and methods to practice zipper entrapment release. Learners were asked to begin a survey prior to training on the model, and then complete the survey immediately after training on the model to evaluate its educational value. The survey created for this study consisted of a structured questionnaire that contained close-ended questions. Measures evaluated include experience with prior zipper entrapments, comfort with zipper entrapments before and after training on the simulated model, and user experience.
Results: Before the exercise, 68.3% of learners described their comfort with managing future zipper entrapments as very uncomfortable or totally uncomfortable. Although only 8.3% of learners had treated the zipper entrapment complaint prior to the exercise, 100% of those who had experienced treating the complaint felt that the simulated model was at least somewhat reflective of their experience with a real patient. 71.7% of the learners found the experience enjoyable, although 20% found the experience totally unenjoyable, of note, for unclear reasons and with unclear significance or etiology. After the exercise, 71.7% of learners indicated they felt comfortable to very comfortable regarding future cases of zipper entrapment.
Discussion: Through the use of a well-known household board game and supplies commonly found in the emergency department, we created a simulated model that could be easily replicated. This simple model provided practice of the hand motions necessary for zipper entrapment release, as well as familiarity with the mental and physical approaches to dislodging the entrapment. The resident physicians who had had a prior zipper entrapment patient reported the model was somewhat similar to actual patient encounters.

Section break
Overall, this model was well-received by the learners, with most expressing it was enjoyable and feeling it increased their confidence for treating this chief complaint. Some learners had noted the experience was totally unenjoyable. This measure may not be an appropriate endpoint, however, and incongruencies may be addressed by implementing prizes or friendly competition for enjoyment. Another limitation of this study is the leap taken between movement and patient comfort. While possible that learners can manipulate the model to reduce movement of the needle without meaningful reduction in zipper movement, observation by the instructor was sufficient to ensure this finding was not observed in our learner population. We therefore submit this cheap, simple model as a potential method to teach approaches to teaching a low frequency, high anxiety chief complaint.

Linked objectives and methods:
The Operation game used in the Zipperator was selected for its alarm feature, which simulates the pain and distress of the simulated pediatric patient. This set-up would encourage learners to explore and attempt various zipper entrapment release techniques with real-time feedback through the alarm feature (objective 1). Hands-on training with the model followed by a debrief will increase learner confidence and comfort with clinical decision-making for this rarely performed procedure (objectives 2, and 3).
Simulated task trainers provide a controlled, safe environment for learners to practice essential procedural skills without risk to a live patient. 7,8 Additionally, past studies indicate that simulation can play a vital role in improving learner confidence and competence as well as patient safety. [7][8][9] Thus, using simulation-based medical education is well-suited to the low frequency, high anxiety presentation of zipper entrapment injuries.
Recommended pre-reading for instructor:

Learner responsible content (LRC):
Learner responsible content is not indicated prior to attending the exercise, especially when used for "just in time" training. Approximately 10 minutes will be needed to assemble the Zipperator. Although learners were not specifically timed, most learners spent an average of 5 to 20 minutes exploring the different techniques of the task trainer, including some who wanted to practice more than once. Therefore, it is recommended that learners dedicate at least 20 minutes to the exercise and up to 40 minutes for those who would like extra practice. One session with the task trainer is sufficient for learners to report comfort with the procedure.

Recommended Number of Learners per Instructor:
Due to brevity of each session, we recommend a ratio of 1 model for every 1 or 2 learners with a faculty or research assistant ratio of 1:1 or 1:2 for a similar experience. However, given the flexibility of this task trainer, other ratios could be explored.

Objectives:
After training on the model, the learners will be able to: 1. Demonstrate at least 2 techniques for zipper release and describe how methods would extrapolate to a real patient. 2. Verbalize increased comfort with the diagnosis of zipper entrapment. 3. Present a plan of care for this low-volume, highanxiety presentation.